Inquest into the Death of Mark Quenton FLEURY

Inquest into the Death of Mark Quenton FLEURY

Delivered on : 17 July 2019

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was subject to a community treatment order (CTO) at the time of his death and an inquest was therefore mandatory. The deceased was 38-years of age when he took his life on 14 February 2016.

After finishing school, the deceased qualified a glazier and for a time he ran his own business servicing the Bunbury area. He married in 2010 and had a daughter but he and his wife subsequently separated in 2012 and she relocated overseas with their daughter in November 2015.

The deceased’s first recorded contact with the South West Mental Health Service (Service) was in 2002, when he was said to be experiencing paranoid, persecutory delusions. These delusions were a consistent theme of his illness and although they responded to treatment, they never entirely remitted.

In 2013 the deceased’s family were concerned that the deceased had become unwell after ceasing his antipsychotic medication. They contacted the Service and the deceased was admitted on an involuntary basis to the Acute Psychiatric Unit at Bunbury Hospital (APU) on 8 July 2013. He was discharged home on 30 July 2013, and made the subject of a CTO.

In January 2014, the deceased’s compliance with his medication and his attendance at the Service became more erratic. His CTO was allowed to expire and he refused to take medication or attend the clinic. On 9 October 2014, the deceased was admitted to the APU, after his family contacted the Service when his mental health deteriorated. The deceased was discharged home on a CTO on 24 October 2014 and he remained subject to a CTO until his death.

On 7 February 2016, the deceased and his mother presented to the Bunbury Hospital. The deceased was seen by the Psychiatric Liaison and discharged to be followed up by the Service the next day. During the following week, members of the deceased’s family contacted the Service and other agencies to report their concerns about the deceased’s mental health. The deceased was assessed by a doctor on 10 February 2016, but did not meet the criteria for involuntary admission to the APU. A similar assessment was made during a phone call between the deceased and his caseworker on 12 February 2016.

On 14 February 2016, the deceased had dinner at his mother’s house. He said he was feeling unwell and had a brief lie down. He left his mother’s home at about 9.30 pm saying he would sleep better in his own bed. Before he left, he and his mother talked about what they could do the following weekend. At about 9.50 pm, the deceased sent his brother a text message saying goodbye. The deceased’s mother and brother became concerned and drove separately to the deceased’s house. They broke in and found one of the bedroom doors was locked.

Police and ambulance officers arrived and forced their way into the bedroom. They found the deceased sitting on the floor of a bedroom with a ligature around his neck, clearly deceased.

The Coroner noted that since the deceased’s death there have been improvements to the Service’s record keeping systems. In addition, emergency action plans had been introduced and peer workers had been employed to support mental health consumers and their carers and families.

The Coroner did not make any recommendations and considered that the supervision, treatment and care provided to the deceased in the period prior to his death was adequate.